Vagina. Does reading that word make you flinch? Or provoke even slight discomfort? Try saying it aloud. We don’t really, do we? Even in 2021, the V word is almost taboo. Whilst we speak freely of the male genitalia, the most powerful part of a woman’s body seems to be the most shameful. Or embarrassing. It’s the unspoken, the unseen. If it is seen, more often than not, it’s sexualised.
Perhaps it should not be surprising that if this part of the anatomy is barely mentioned, discussion around female perineal discomfort or, whisper it, disfiguration, is even rarer. Transpose this into the world of cycling, where most team staff are men, and you have a hidden, ticking time bomb.
“It has always been super, super hard to talk about it because you’re always in a team where you have men sitting you on a bike, and I felt really uncomfortable with that,” explains Lisa, a top professional rider who had labial surgery last year after a decade of suffering.
“It made me emotional and still does because it’s something that I don’t want to talk about with these guys. It’s very private so you’re not just going to throw it out there.”
Lisa (not her real name) first noticed a problem some ten years ago. “My left labia was much bigger than the right one. I can’t really remember it ever being good, I always had these problems. I could sit on my saddle so it was not painful or bothering me from riding so much, but it was very uneven. My pedalling wasn’t straight because one side was higher than the other.”
As seems to be common with sufferers of labial discomfort, she tried to ignore it. “I don’t like to go to the doctor to ask what I can do or the idea of somebody cutting my vagina. And also, you’re out for a while so you really need to plan it at the end of the season.
"It got worse and worse and worse. It got really, really big in the end to the point that I would only sit on one side.”
After leaving the problem untreated for ten years and, worse still, consistently aggravating it with her day job, when Lisa sought medical advice in 2019, surgery had become her best option. But there were complications.
“I think I was kind of an exception because I waited so long for surgery. Normally it takes one hour or so, and it took three. My boyfriend was super worried. And then the doctor said it didn’t really go as planned, so I had to stay another night.
“That was pretty horrible because I had so much pain and it became really swollen. My boyfriend did everything. He changed my whole bed when there was blood everywhere… it was a nightmare.”
“I went home and during the next two days, the swelling got worse. It got to the size of a tennis ball. I was terrified. I was like, I don’t know if this is ever going to get back to normal. It’s an area that I think normally heals fast, but this was such a wound that it took very long.
“I had to have all these lymph massages to get away the fluid from the surgery. I was also feeling super awkward going to this physio. I wanted to have an older lady because it’s not really nice when somebody is massaging your vagina. Well, it can be, but not in this case!
“In the end I just had to have patience and now it’s really back to normal - whatever is normal. You don’t see anything weird now. I’m very pleased with it and I really wouldn’t have thought that in the first week. That was a very terrifying week.”
The extent of the issue
Vera Koedooder has also suffered chronic labial pain and swelling for most of her cycling career. A former Dutch and junior world track champion, Vera rode professionally on the road until 2017. She retired partly because of the agony caused by her labial growth and subsequent surgery scarring.
Like Lisa, Vera hid the extent of her problem for many years, but mainly for professional reasons.
“I already had injuries down there when I was 15 or 16. As a first-year junior, I was national time-trial champion but I did not get the selection for the World Championships, mostly because of the national coach.
“She was angry because after seeing my injury, the national team doctor told that I was not able to ride for the next couple of weeks for more than one and a half hours at a time.
“The coach got upset because I couldn’t do the long rides on training camp and I didn’t get picked. I didn’t dare talk much about it in the years that followed because I thought I’d get punished if I would need a week’s rest.”
The problem only became worse: “The right side was ten times bigger than the left and I always had pain on the bike.
“After a rest period the swelling was maybe the size of a mandarin, but a long one. After a race it could be like a grapefruit, a banana or something.”
She did have it operated on, as part of a separate surgery on her femoral artery in 2005, but the growth had become so large that the body had made its own nerves and it couldn’t be entirely removed.
“If they cut the whole thing off, I would lose a lot of veins and nerves. When they stitched what they had cut, the scar was also really big and long and still gives friction nowadays.”
Statistics on labial surgery among cyclists are difficult to come by, but the gynaecological experts and sports medicine specialists contacted for this article each reported an increase in women presenting in recent years. This tallies with wider society: the American Society of Plastic Surgeons reported a 9 per cent increase in labiaplasty last year.
The evidence from cycling overwhelmingly suggests that surgery in the sport is not primarily for cosmetic reasons. Luc Baeyens, a Belgian gynaecologist and world leader on “bicyclist’s vulva”, currently sees three to four patients a month with labial lesions or swelling. It used to be a single patient every two months. He believes the increase is largely because of better awareness, but says embarrassment is still a big issue: “It is still taboo. Very slowly we do hear more about it.
"Female cyclists do talk about it a little more amongst themselves, sports doctors have started to speak about it, but it is still hidden.”
Baeyens wrote a medical paper on bicyclist’s vulva, published in the British Medical Journal in 2002. The term refers to a swelling of one of the outer labia and is most commonly caused by too much pressure on the saddle and too long spent in the forward, aggressive riding position. It is a condition thought to be found in one in five competitive female cyclists, but is also seen in equestrian sports.
Despite its prevalence, there is an historical ignorance, even within the medical profession. “The first studies on the perineum of male cyclists dates from 1897,” Baeyens says. “The first I found for female cyclists is 1993. That’s a huge difference.”
The traditional lack of medical literature is compounded by popular media reporting that often focuses on the sensational or the sexual. Headlines such as ‘Cycling is ruining your vagina and hurting your sex life’, or ‘Cycling Could be Making Your Lady Bits BIGGER and Your Sex Life WORSE’ offer much in terms of scaremongering and little in terms of reference points for anyone requiring medical attention.
Shame and widespread ignorance is a potent combination. Sufferers often leave treatment so late that the problem becomes acute and don’t always encounter informed expertise. Baeyens tells of a former professional rider who had previously seen a gynaecologist about her enlarged labia. The doctor had asked whether she had previously been a man, so unaccustomed was he to such swelling. His only frame of reference was testicles.
Hannah Dines is a leading British Paracyclist who has spoken openly about her experience of labial surgery. She too found a disturbing ignorance of the nature and severity of the problem
After telling a team physio, who no longer works at British Cycling, “I’ve really got a problem, my right side is huge”, the response was “all female cyclists get that.” There was no physical examination.
Hannah persisted, partly because the swelling was becoming so serious. “I went on this really potholey ride in Scotland in 2018 and then I was like, wow, the right side of my labia is huge, it’s basically a ball now. I was scared.”
“I sent round robin emails to my team-mates once a year, saying this is a big thing.”
By the time Hannah did receive a physical consult, it was with a plastic surgeon acquaintance of her mother. “He looked at it and said this is not normal. That scared the shit out of me. He said it was likely to be cancer, that he’d seen a lot of labial cancer in people as young as myself.
“I was so cross because at every point I’d been really quite vocal about it. I was like, why is this a thing? I’ve got this massive lump - why hasn’t anybody said this could be cancer, way back?”
Happily, it wasn’t cancerous and Hannah had the lump removed after five years of pain and chronic swelling.
“A lot of it was internal and when it was taken out, I actually asked how big it was, and he said it was the size of a grapefruit. It didn’t present like that on the surface, it was much less than that, but it was like three walnuts together.
“I’ve had a lot of surgery in my life for cerebral palsy and it is not something that I’d jump into. You’ve got to think about it thoroughly, it’s not always the answer.
“You can get a haematoma from the wound, so you can basically swell up with blood and you can have sexual dysfunction if it cuts a nerve or something. I had none of that and I was out of the hospital in a day.
“I thought it was going to be so much worse because I’ve had huge surgeries before, but this was just brilliant. Now, I wouldn’t say I have the best vulva in the world, but you can’t see I had surgery on it and I’m cycling on it still.”
Prevention is better than cure
Such invasive medical recourse is, indeed, a last resort. Even Baeyens, who treats patients from all over Europe, “only operates exceptionally, five to six a year, no more. I avoid it where I can, because operating will damage the lymphatic pathways even more so we risk making the swelling worse.”
For him, the best treatment is early intervention or “prevention, prevention, prevention.” Specialized's Mimic technology is improving cycling for many women. Rather than featuring a cutout — which was widely considered the answer to all saddle woes — the Mimic, and latterly Mirror, saddles have a small, cushioned dip in the middle. Image credit: Sean Hardy
What does that look like? Hairier than current aesthetic trends for a start. “No Brazilian wax, that’s important,” he says. “The hair gives a protective layer but also, when it regrows, it can grow inwards and you absolutely must avoid that. You can do what you like on the pubis but you should not shave the hair on the perineum.
“If there is the slightest lesion, I recommend that you clean with a disinfectant in the shower after every ride. Always apply an ice pack if you have any swelling, and stay for ten to 15 minutes with your legs up after a ride.”
The fit and angle of the saddle are crucial because of pressure on the lymph system. “You need to not be [sat] too far forward and regularly stand up on the pedals to relieve the pressure. I recommend a saddle angle of 5-6 degrees.”
Mark Ridgewell, a leading British consultant in sport and exercise medicine, says there is no one saddle to suit everyone and recommends finding the best fit for you as part of an overall checklist.
“Check if your anatomy is okay. If it is, are you being good with your fluid intake to stop you getting cystitis? Are you changing your cycling shorts every day, not wearing underwear and keeping everything as clean as can be? Are you using a chamois or Vaseline as a moisturiser?
“If you can, cycle a bit more upright but maybe not for 100 miles. Ideally, you’d do a saddle trial – you’d go to a shop where you can try a saddle out properly for a week that you can return. There isn’t one saddle that I can recommend because all women are different.”
Ridgewell says it’s important to realise that surgery is not the only option for anyone suffering pain or discomfort.
"Vulval issues are a problem and there is surgery at the end of a line, but the first thing would be, if you’re anxious about it, ask a female GP or a gynaecologist, and ask whether the anatomy is normal."
“If you‘re a man with testicular pain, I’d tell them to see a GP. That’s the first place to start. It’s important to give people a structured pathway that’s not terribly embarrassing to start with, that goes a conventional route rather than have them thinking, oh my God, I might have to have an end result of surgery.”
Education is needed all the way through the sport, from the top down. “I don’t think teams are aware of the extent of the problem,” says Lisa. “It affects your whole life because you go training daily for hours and hours, and you think in the morning, oh no, I have to go on my saddle again.
Many professional teams still insist on using the saddles of team sponsors, even if they’re compounding the problem. “In one team, at one point I said ‘if I have to ride this, I’m just not going to do a stage race any more. Don’t put me on the start list because it’s not possible,’” says Lisa.
“Also, in that team, other girls had issues with saddle sores and the doctor just gave them antibiotics and you keep riding with your saddle. I’m like, I think there are different ways to solve this problem!”
It’s little wonder there is still a lot of work to be done on the cycling shop floor too. Jasmijn Muller, a former British and world ultra-distance champion who’s had two labial surgeries, believes more education is needed in bike shops. “Staff are still uncomfortable talking to women about saddles. Then there’s a lot of, ‘here’s our women’s saddle’. They have one that works for some other woman, therefore they think it should work for you. Whether it’s more female staff or education for the male staff, I would love to see that. In the same way a personal trainer can do courses and learn to be comfortable talking about all issues with men and women, it would be great if we had a similar approach to education with male bike shop staff.”
Hannah Dines also feels that a more fundamental shift in the industry’s view of female cyclists is inevitable. “I think since the 2019 woke boom, people have realised you don’t just paint it pink and slap ‘this is for girls’ on it. You can actually make a very lucrative business out of specialised products for certain issues.
“Hopefully we’ll have a wave of women - noisy, loud women - who can stand up and say, no, this is a problem because it’s causing me real damage. It just takes loads of us at once, and I think that’s happened and is happening.
"Hopefully the industry will have to change.”
Dispelling the taboo and shame around discussion of the vagina can only help a more open conversation. For that, we should consider the framework of popular discourse. We speak easily of testicles, mostly to imbue them with some kind of superpower. We’re told we need to “grow a pair” if we’re not displaying significant fortitude. Someone is congratulated as being ballsy if they have demonstrated particular courage. In contrast, we dismiss someone as being a “fanny” if they’re seen to be frivolous, weak or unimportant. One is capable of withstanding the trauma of pushing a fully-formed human into the world, stretching to up to three times its size to do so; the other cannot tolerate the application of even moderate force.
If there was a part of the anatomy to be associated with strength, resilience and power, it is the vagina. Language matters. It reflects and helps to shape the thinking of both the individual and the collective. Perhaps if we were less embarrassed by vaginas, we could facilitate a more frank discussion when there are problems. It seems ludicrous that we should even need to say this, but it is time to stop being so embarrassed about an essential part of the female body. The vagina is nothing to be ashamed of. Balls to anyone who says otherwise.